Basic Information
| Provider Information | |||||||||
| NPI: | 1417012360 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHOI | ||||||||
| FirstName: | IN SUP | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | LAHEY CLINIC | ||||||||
| Address2: | 41 MALL RD | ||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817445100 | ||||||||
| FaxNumber: | 7817445630 | ||||||||
| Practice Location | |||||||||
| Address1: | LAHEY CLINIC | ||||||||
| Address2: | 41 MALL RD | ||||||||
| City: | BURLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018050001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7817445100 | ||||||||
| FaxNumber: | 7817445630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2006 | ||||||||
| LastUpdateDate: | 01/08/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085N0700X | 41475 | MA | Y | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | 41475 | MA | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 3099121 | 05 | MA | MEDICAID |